A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

A drop in heart rate from 74 to 68/min.

A change in the Glasgow Coma Scale score from 14 to 10.

Headache.

Diplopia.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is incorrect because a drop in heart rate from 74 to 68/min is not a manifestation that requires immediate reporting to the provider. A mild decrease in heart rate can be normal or due to other factors such as medication, sleep, or relaxation. It does not indicate a worsening of brain injury or increased intracranial pressure.

Choice B reason: This is the correct answer because a change in the Glasgow Coma Scale score from 14 to 10 is a manifestation that requires immediate reporting to the provider. The Glasgow Coma Scale is a tool that measures the level of consciousness based on eye-opening, verbal response, and motor responses. A score of 14 indicates mild impairment, while a score of 10 indicates moderate impairment. A decrease in score can indicate deterioration of neurological status and increased intracranial pressure, which can be life-threatening.

Choice C reason: This is incorrect because the headache is not a manifestation that requires immediate reporting to
the provider. Headache is a common symptom of mild TBI and can be managed with analgesics, rest, and hydration. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is severe, persistent, or accompanied by other signs such as vomiting, confusion, or seizures.

Choice D reason: This is incorrect because diplopia is not a manifestation that requires immediate reporting to
the provider. Diplopia means double vision and can be caused by damage to cranial nerves or eye muscles due to TBI. It can be treated with eye patches, glasses, or surgery. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is associated with other symptoms such as blurred vision, loss of vision, or eye pain.

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Correct Answer is D

Explanation

Choice A Reason: Colorectal cancer is not likely to cause nausea with projectile vomiting or high-pitched sounds in the left upper quadrant. Colorectal cancer may cause symptoms such as rectal bleeding, change in bowel habits, abdominal pain, or weight loss.

Choice B Reason: Paralytic ileus is a condition where the bowel stops working and does not contract or move food along. Paralytic ileus may cause symptoms such as abdominal distension, absence of bowel sounds, constipation, or vomiting.

Choice C Reason: Large bowel obstruction is a blockage of the colon or rectum that prevents the passage of stool. Large bowel obstruction may cause symptoms such as abdominal distension, low-pitched sounds in the right lower quadrant, constipation, or ribbon-like stools.

Choice D Reason: Small bowel obstruction is a blockage of the small intestine that prevents the passage of food and fluids. Small bowel obstruction may cause symptoms such as nausea with projectile vomiting, high-pitched sounds in the left upper quadrant, abdominal cramps, or dehydration.

A. "Your allergies have most likely contributed to this." B. "Your history of gastroesophageal reflux disorder is the most likely cause." C. "Being a vegetarian has caused an imbalance in stomach acid." D. "This is a genetic condition that you were born with."

Correct Answer is B

Explanation

Choice A reason: This is incorrect because allergies are not a risk factor for developing Barrett's esophagus. Allergies are hypersensitive reactions of the immune system to certain substances, such as pollen, dust, or food. They can cause symptoms such as sneezing, itching, or hives, but they do not affect the esophagus or stomach acid.

Choice B reason: This is the correct answer because gastroesophageal reflux disorder (GERD) is the most common risk factor for developing Barrett's esophagus. GERD is a condition where the lower esophageal sphincter (LES) does not close properly and allows stomach acid to flow back into the esophagus. This can cause inflammation, irritation, and damage to the esophageal lining. Over time, this can lead to changes in the cells of the esophagus, which is called Barrett's esophagus.

Choice C reason: This is incorrect because being a vegetarian is not a risk factor for developing Barrett's esophagus. Being a vegetarian means avoiding meat and animal products in the diet. This can have health benefits such as lower cholesterol and blood pressure levels, but it does not affect the esophagus or stomach acid.

Choice D reason: This is incorrect because Barrett's esophagus is not a genetic condition that one is born with. Barrett's esophagus is an acquired condition that results from chronic exposure to stomach acid in the esophagus. It is not inherited from one's parents or passed on to one's children.

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A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client arrives to the emergency department complaining of acute onset of nausea with projectile vomiting. The nurse's assessment findings include high-pitched sounds in the left upper quadrant. Which gastrointestinal disorder is consistent with these findings?

Correct Answer is D

Explanation

A client diagnosed with Barrett's esophagus asks how he developed this. Which of the following responses by the nurse is most accurate?

Correct Answer is B

Explanation

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